As legal psychedelic therapy emerges, ethicists urge for more comprehensive frameworks to address sexual abuse

Editor’s note: The contents of this article may be triggering to those who have suffered from ethical violations and/or trauma of a sexual nature.

In his 1985 testimony for the Drug Enforcement Agency’s MDMA scheduling hearing, a therapist by the name of Richard “Rick” Ingrasci made a convincing case for the legalization of the drug as an adjunct to psychotherapy. He clearly laid out the action of the drug and the methodology for its use as a tool in therapy. Many of his methods, such as dosage and the “gentle non-directive” approach of the therapist, are still standard practice today. 

Alongside this information, Ingrasci included compelling cases from his own underground MDMA-assisted therapy sessions. These cases included patients overcoming marital connection issues, cancer patients coping with end of life anxiety, and patients overcoming childhood sexual assault.

“My professional experience with MDMA leads me to conclude that it is a substance which has a low potential for abuse,” Ingrasci wrote in his testimony. 

Ingrasci’s testimony on MDMA’s abuse potential only happened to focus on addiction and dependency, though, not the abuse potential of the power dynamics between a therapist and a vulnerable patient under the influence of MDMA. 

Four years after his testimony — on July 11, 1989 — Ingrasci resigned his medical license to the Massachusetts Board of Registration in Medicine amidst accusations that he sexually abused multiple former patients. One woman approached him for counseling after learning of her cancer diagnosis and was told that sexual contact could help heal her ailments. Other women stated that Ingrasci sometimes administered MDMA or ketamine to them and inserted his hand in their vaginas, and had at least one woman perform oral sex on him under the influence.

Boston Globe journalist Alison Bass reported in 1989 that one woman who was sexually assaulted by Ingrasci attempted suicide after terminating her therapy sessions with him. And, two other women told her that they were emotionally devastated by the experience and only at the beginnings of their recovery. 

The charges of malpractice were dropped after Ingrasci resigned his license. And, he went on to co-found the Hollyhock Lifelong Learning Center in British Columbia, co-found a traveling immersive film project called StoryDome, and serve as a board member of the investigative journalism outlet Yes! Media, proudly listing his “M.D.” credentials wherever possible.

Ironically, the last tweet on his Twitter profile (@BigMind) reads:

University of Pennsylvania ethics professor Jonathan Moreno told me that the way Ingrasci’s career panned out is all too common among medical professionals accused of having sex with patients. They weather the storm of accusations until they get too intense, resign their license, and see their actions relatively swept under the rug. 

Rick Doblin — founder of the Multidisciplinary Association for Psychedelic Studies (MAPS), which is conducting FDA trials for MDMA-assisted psychotherapy — said that he was shocked when he found out about Ingrasci’s misconduct. The two of them were contemporaries in the DEA’s scheduling hearings throughout the 1980s.

My take is that even people who are highly respected and appreciated sometimes violate ethical boundaries out of personal weaknesses,” Doblin said.

Cases abound of medical practitioners violating these ethical boundaries. It should be noted that a comparable amount of these violations occur without the introduction of psychoactive drugs, at all. Many people will tell you that this behavior could just as easily happen between a general practitioner and their patients.

“I would generally agree with that,” said Dominic Sisti, a University of Pennsylvania professor of medical ethics who has consulted with MAPS to develop a code of ethics for MDMA-assisted psychotherapy research. 

“I think the one distinction is, you could imagine a patient [on MDMA] becoming attached more easily with a therapist. In that case, the direction would be from patient to clinician. But, if its going from clinician to patient, you could put that clinician in any context and you’d still have a problem. That is why I think making sure that the training and, really, the vetting of the character of these therapists is so important.” 

With the “breakthrough therapy” designation of drugs like MDMA, ketamine, and psilocybin by the FDA, these substances are being fast-tracked through approval processes and the field of psychedelic-assisted psychotherapy is quickly approaching on the horizon. 

 

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Organizations like MAPS, Usona, and Compass Pathways have a lot to think about when it comes to protection of patient rights. It is worth taking a retrospective look at cases like Ingrasci’s, or Francesco DiLeo’s almost identical conduct, or best-selling author and psychiatrist Harold Bloomfield’s drugging of multiple patients’ with MDMA. 

But, the most relevant and nuanced case might be one that came to light just last year involving therapists participating in MAPS’s FDA approval studies.

In 2018, the team of MAPS co-therapists were reported to the College of Psychologists of British Columbia, the BC College of Physicians and Surgeons, and MAPS Public Benefit Corporation. The complaint named the co-therapist team, a married couple named Richard Yensen and Donna Dryer, as being involved in inappropriate and unethical sexual behavior with a patient. According to MAPS public statement, the female participant who filed the complaint was enrolled in studies December of 2014 and completed active treatment in October of 2015. After moving to the therapists’ town on Cortes Island — coincidentally where Ingrasci helped create the Hollyhock Lifelong Learning Center — she continued follow-up treatment.

“At the end of 2015 or early 2016, the relationship between Richard Yensen and the participant became sexual in nature,” according to MAPS public statement. “Donna Dryer reportedly became aware of this and tried to stop the sexual relationship but was unsuccessful. She did not report it to MAPS or any regulatory agencies. Over time, the participant grew uncomfortable with this relationship and eventually moved away in early 2017, breaking ties with both therapists.”

In response to the civil case filed by the patient against Yensen and Dryer, the two claim that at all times the patient consented to the intimate relationship. Even if this were the case, though, consent isn’t the point. At one point Yensen was her acting co-therapist, interacting with her under the influence of a powerful psychoactive drug. Any sexual activity with patients is deemed unethical conduct by the American Psychology Association and other professional organizations. 

“Sexual relationships make it impossible to maintain an open and trusting therapeutic relationship between a clinician and their patient,” Sisti said. “As the power dynamics are inescapable, the prohibition on sexual contact should be absolute.”

Some researchers who study sexual relationships between therapists and patients compare the practice to incest, because patients often transfer longstanding feelings for their parents to their therapists. Researchers say female patients who are taken advantage of in this situation often lose trust in the therapist, psychologists, and men in general. With this in mind, examine this piece of writing which the patient published in 2016 about her experience in active treatment for MAPS’ FDA clinical trials — it drips with issues when looked at retrospectively, knowing her relationship with her therapist turned sexual:

There were two [therapists] with me at all times. Hugging me often. Holding me as I cried. Providing the touch I craved as much as feared. Denied yet ached for, with the longing of a child unsure of what was safe. Therapeutic breakthroughs occur on the edge of consent. They pushed me hard, my toes curling in protest. But each time I fell they were there. Holding my fragments together until the wounds mended enough to carry on. As we journeyed through that gauntlet of horror, our alliance was forged. I was literally loved back to life.

These therapeutic breakthroughs “on the edge of consent” take on a slightly different shape when referred to, in the lawsuit filed after she moved away from the therapists in 2017, as manifesting in “erosion of self-esteem, self-sufficiency, and confidence” and “on-going difficulties in dealing with, and impaired ability to trust, the health care professionals” among other claims of psychological harm.

MAPS has developed a practice of using male-female co-therapy teams, like the team in this case, to provide insight that a one-person, one-gender team may not have. And, to help prevent sexualized behavior by either therapist during or after sessions, according to Doblin. However, as illustrated by Yensen and Dryer, sometimes issues can arise even with a married, male-female team.

Both Moreno and Sisti, the University of Pennsylvania medical ethicists, believe that psychedelic-assisted therapy should be moving toward a team-focused approach — with therapists, nurses, chaperones, and primary care physicians involved. They believe that the issue with Yensen and Dryer was handled swiftly and transparently by MAPS, who released a public statement saying they will not be working with either of the therapists in the future and paid their patient $15,000 to receive therapy elsewhere while she pursued legal action. This kind of response is rare, Moreno said. 

Having two therapists in a room is already one level above what a typical psychotherapy session has,” Sisti said of MAPS therapy protocols. “But, then they also have cameras and monitoring so that the session is recorded and can be used for supervision reasons. So, they can learn and watch a session and see what went right and find areas for improvement. With that kind of oversight and monitoring, it certainly adds an extra level of safeguarding, which is beneficial.”

Doblin also said that when on-boarding therapists and Schedule 1 license holders, MAPS does a criminal record check on all applicants. They also check people’s therapeutic licenses and require at least one therapist to have a current license.

“We spend a fair amount of time with people during the training process and will not approve people we’re not comfortable with to be able to work with patients,” Doblin said. “Nevertheless, even with all these precautions, some therapists may still take advantage of patients, potentially for the first time.” 

With the help of medical ethicists like Sisti and Moreno, MAPS developed an MDMA-Assisted Psychotherapy Code of Ethics, released in 2019, which specifically addresses sexual relationships and sexual touch. 

Broadly, the document states that “participants in non-ordinary states of consciousness may be especially open to suggestion, manipulation, and exploitation; therefore, we acknowledge the need for increased attention to safety and issues of consent.” And specifically, we do not engage in sexual intercourse, sexual contact, or sexual intimacy with a participant, or a participant’s spouse or partner, or immediate family member, during the therapeutic relationship or after termination.”

Shannon Carlin, MAPS Director of Training and Supervision, said that sex is something explicitly addressed in training sessions with therapists.

“We discuss sexual boundaries and erotic transference and counter-transference,” Carlin said. “This is standard training for therapists, but we highlight additional need for integrity due to long sessions, deep trauma, and non-ordinary states.”

Sisti believes that MAPS is on the right track in creating this framework, but he sees the need for developing an actual professional society for psychedelic medicine and some sort of licensure process, too. Nearly every profession has this kind of mechanism in place, he said. This way the society can self-police, adjudicate complaints, and discipline individuals who may breach the code of ethics in various ways. 

Carlin said that there is currently a small group of clinicians working on creating a future professional board and licensing agency for psychedelic therapy. Until then, the patient complaint review process is being handled by an Independent Review Board.

In 2012, Moreno reported in a Psychology Today piece titled “Sex With Patients Revisited” that his impression is that sexual exploitation by psychotherapists has actually been lessening over time. 

“A review of various surveys from 1977 to 1994 suggests that the problem has somewhat lessened,” he wrote. “The 1977 survey found 12 percent of male therapists and 2.6 percent of female therapists reported sex with clients; in the 1994 survey the numbers were 3.6 percent and 0.5 percent.”

Moreno attributes this potentially to the fact that, over time, fields in which talk therapy are practiced have become dominated by women. And, while psychiatry is still a fairly male-dominated field, it is now mainly a pharmaceutical practice. Another contributing factor he addresses is that there are different insurance arrangements than there were decades ago, when much talk therapy was out-of-pocket.

“There is far more scrutiny by third-party payers,” Moreno writes. “So, also there is less long-term therapy (for better or for worse), in which vulnerabilities could gradually be exploited.”

Widening the scope, a recent review published in the journal “Sexual Abuse” examined 101 reported cases of sex between patients and physicians of all backgrounds. All of the cases involved a male physician, most of whom were older than the age of 39. And, well over half of them were not board-certified, practicing in non-academic settings where they examined patients alone. Like Moreno mentioned, most — but not all — of these physicians (who were licensed) ended up losing their license after a board investigation. And, while most cases were criminally investigated, only a little over half of the cases examined ended in any criminal punishment. An even smaller percentage of these physicians (around 34 percent) received any increased monitoring or oversight after their conduct was initially addressed. 

“I think the overarching issue here related to sexual encounters in therapy — while this is a new cut to it, vis a vis MDMA — its not a new issue, in general,” Sisti said. “It just has to be tackled in this context.” 

Clearly, ethical compromises by physicians exist throughout the scope of professional medicine. But, as the field of psychedelic-assisted psychotherapy evolves into the mainstream therapeutic arena, there is a unique opportunity to center consent and enforce strict ethical standards for practitioners. As a practice with a storied history of sexual abuse, the emerging field of psychedelic-assisted psychotherapy has an obligation to ensure that the problematic elements of the existing cultural paradigm are transparently and conscientiously addressed.

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